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Questionnaire on Stress Management - PDF - PDF

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					                                               Stress Questionnaire
Directions: In the blank in front of each item, write the number that best indicates how intense
of stress that item is for you. Add additional items to the end if needed. Remember to keep this
questionnaire. You will need it for the rest of the workshops.

Stress Intensity Ratings
0 = Not at all        1 = Somewhat                            2 = Moderate                   3 = Severe

_____ Health problem or injury of myself or family member
_____ Too much to do or long work hours
_____ Machinery breakdown or stock problem
_____ Purchased new machinery, building, or land
_____ Crop or stock loss
_____ Unreliable prices for the products I raise
_____ Handling pesticide
_____ Financial difficulties in my farm or business, including too much debt
_____ Problems with government regulations, legal issues, or bank
_____ Not enough money for family needs
_____ Dealing with the weather
_____ Conflict with operating partner or farm help
_____ Conflict with my spouse or life partner
_____ Conflict with my kids
_____ Difficulties with relatives, including in-laws
_____ Helping an older relative with health or home management
_____ Conflicts with friends or neighbors
_____ Difficulty getting or keeping a job or second job, or job conflicts
_____ No one to talk with about my troubles
_____ Not enough time to do the farm/or job things I want to do
_____ Too little time for my family
_____ Not enough hobbies, recreation, and entertainment
_____ Too much time on my hands in some seasons
_____ Dealing with recent death of someone close to me
_____ Dealing with Divorce or separation
_____ Pregnancy or recent birth in our family
_____ Change in living situation, including child growing up and moving out
_____ Marriage, big personal achievement, etc.
_____ Promotion, retirement, or job changes
_____ Other stress:_______________________________________
_____ Other stress:_______________________________________
_____ Other stress:_______________________________________

_____ TOTAL

Total Stress Intensity Levels
High = 30 and higher         Medium = 15-29                               Low = 14 and under

             Developed by Kay Slama, Ph.D. (June 2009) for the Dealing with Stress: Web-based Educational Series. Visit
 www.extension.umn.edu/ToughTimes/dealing-with-stress.html for more information. This has been adapted from Holmes & Rahe’s (1967)
                     Holmes-Rahe life changes scale (Journal of Psychosomatic Research, 11, 213-218, Elsevier).

				
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